There has been a considerable increase in the number of academic leagues active within undergraduate medical courses in Brazil over the last few years. However, this phenomenon has not been accompanied by adequate reflection on its determinants, on the role of the leagues within the institutions or even on their pedagogical function. From these observations, the authors analyze the scant literature on this topic, describe the experience of the academic leagues of Botucatu Medical School, Unesp, and reflect on the role of these leagues in medical training, in an attempt to partially fill this gap and contribute towards this important discussion.

The medicine course has a full-time structure, with an enormous quantity of theoretical-practical content and, in the majority of medical schools in Brazil, with few optional disciplines and scant time available for extracurricular activities. Besides this, as a rule, the contents are ministered with little integration between the disciplines and with insufficient integration between theory and practice, which tends to make the teaching-learning process of minimal significance and, consequently, less productive (Feuerwerker, 2005). In general, it is also a course that involves a high degree of competition between the students, since the university entrance exam is extremely competitive and the selection exam for residency programs represent a narrow funnel at the end of six years of graduate level, which the students become concerned about at an ever earlier stage. This climate of competitiveness is not restricted to the beginning and end of the course, but extends throughout, revealing its existence with every disclosure of grades or other situations in which the students feel or, indeed, are evaluated/classified.

Early in the initial years of the course, the student is placed in contact with the huge emotional load of the suffering of others, with a growing degree of responsibility regarding the patients attended and little or no "space" envisioned within the curriculum where such emotional experiences are partially shared between their peers or "metabolized" with the help of professors or tutors adequately prepared for this function (Ramos-Cerqueira, Lima, 2002). As Peres and Andrade (2005) highlighted, the medical student is subjected to an extenuating work schedule and enormous demands from the perspective of their emotional maturation and is subject to sources of tension that are generally not contemplated by the instituted curriculum. Indeed, some studies conducted in this area have indicated high rates of mental suffering among students of medicine (Lima, Domingues & Ramos-Cerqueira, 2006; Moro, Valle & Lima, 2005; Souza, Menezes, 2005).

On the other hand, the professional context of the university professors in Brazilian public medical schools is not that different to that lived by the student, in terms of demands. In general, aside from teaching activities, there is an expressive burden of assistential and administrative activities, as well as the enormous pressure for scientific productivity. The time dedicated to graduate teaching activities normally need to be divided with the teaching of postgraduate senso latu (medical residency programs) and senso estrito. The professor has little or no specific preparation for pedagogical activities (Fernandes, 2001), exercising this function, in general, intuitively, reproducing models - equally unprepared - that they came in contact with during their own graduation course. Greater value is attributed to teaching activities linked to postgraduation, the number of students oriented or works published in high impact scientific journals and funds granted by agencies that support research, in comparison with activities developed with graduate students. Thus, overloaded with obligatory commitments and eternally up against the clock, both the student body and the professoriate see themselves in a rat race of activities that they execute without much liberty, reflection or pleasure. In this context, academic leagues1 (ALs) have been gaining strength progressively, developing as extracurricular activities.

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According to Azevedo & Dini (2006), there is no clear concept of what ALs are, although some general considerations can be outlined: they are student organizations in which a group of students "decide to make a profound study of a specific theme and resolve the demands of the population". It is up to the students to define the direction of the League, oriented by one or more professors. Thus, besides classes, courses, research activities and assistance in different scenarios of medical practice, the insertion of students into the community is important, whether by means of educative activities or the promotion of health, such as health fairs and campaigns, aimed at improving the quality of life of the population and acquiring more experience and knowledge (Azevedo & Dini, 2006).

ALs were initially idealized in Brazil at a time of great political-social tension, corresponding to the years of military dictatorship. In this context, student associations began to question the essence of university teaching and the direction and applicability of technical-scientific advances. During the last 21 years of redemocratization and profound changes in Brazilian society, it was concerning approaches to health care and curriculum reform that the first ALs were formalized (LETTUFPE, 2007).

The constitution of 1988, in which the principal of the nondissociability between teaching, research and extension was elaborated, strengthened the role of the ALs. Created in 1996, the Law of Directives and Bases of National Education defined the role of higher education in academic practice and formation, highlighting the stimulus to knowledge of the present problems of the world, as well as national and regional problems. The practical results are revealed in providing services to the community and in the establishment of a reciprocal relationship with the same. Thus, university extension activities try to ensure that research and academic studies reach the community more rapidly through professional practice (Salgado Filho, 2007).

Ideally, it is expected that the ALs constitute "spaces" where the student can act within the community as an agent of health promotion and social transformation, increasing the object of medical practice, recognizing people as actors in the health-disease process, which involves psychosocial, cultural and environmental aspects and not just biological. Thus, besides the development of critical sense and scientific reasoning, they propitiate a more ample practice of the exercise of citizenship, looking at the social needs and integrality of health care (Salgado Filho, 2007; Azevedo & Dini, 2006; Mafra, 2006).

The participation of students in ALs occurs in spheres of actions in health, teaching, research and extension; aspects that, despite the structural divergences in the different scenarios of medical teaching, are relatively homogenous in all regions of Brazil. This fact is reflected in the creation of the Brazilian Association of Academic Leagues in Medicine (Associação Brasileira de Ligas Acadêmicas de Medicina, ABLAM) (ABEM, 2007), in September 2006, during the 8th Brazilian Congress on Clinical Medicine held in Gramado, Rio Grande do Sul, which represented a landmark in the history of Brazilian medicine, counting on the support of numerous regional and national medical entities.

Academic Leagues in the Botucatu Medical School

In the Botucatu Medical School (Faculdade de Medicina de Botucatu, FMB) of São Paulo State University (UNESP), 16 official ALs currently exist (October, 2008): the Trauma League, the Cancer League, the Surgery League, the Geriatric and Gerontology League, the Heart League, the Pain and Palliative Care League, the Sexual and Reproductive Health League, the Mental Health League, the Intensive Medicine League, the Pediatric League, the Pneumology League, the Coloproctology League, the Neurosciences League, the Dermatology League, the Diabetes League and the Transplant League. Another league is in the process of accreditation: the Women's Health League.

ALs are generally conducted by an executive board composed of a president, vice-president, treasury and secretary, usually administered for a year and they are structured in different fronts of action. The principal fronts and the respective functions are: the Clinical Front, which organizes the practical activities of the students, such as shifts and outpatient or nursing attendance; the Capacitation Front of its members, which organizes seminaries, clinical case discussions and revision and/or actualization classes; the Scientific or Events Front, which organizes Meetings or Congresses; the Research Front, which organizes activities for the production of knowledge; the Preventive and Educative Front, which prepares materials and organizes education in health activities, such as participation in Campaigns and Health Fairs; and the Therapeutic Support Front, which organizes and develops complementary activities for patients who are already being attended by the health system. In the specific case of the Mental Health League (A Liga de Saúde Mental, LISM), created in 2004, there is also the Students Mental Health Front, which organizes integration activities between old and new members, the reception of first-year students and even cultural and leisure activities, such as the cine-club and literary, philosophical or musical evenings, among others.

Periodic meetings formalize and manage the functioning of each AL, planning concerning the activities to be developed, internal organization and the process of selecting new collaborative members among the students.

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In 2005, the Council of the Academic Leagues (Conselho das Ligas Acadêmicas, CONLIGAC) of the FMB was created, linked to the Pirajá da Silva Academic Center, organ for student representativity. This council plays a fundamental role in the organization and articulation of the activities developed by the different ALs, by means of periodic meetings with their representatives, and in evaluating the merit of proposals to create new Leagues. Later, the formalization process of the same is also judged by the Permanent Commission for University Extension (Comissão Permanente de Extensão Universitária, CPEU) and the Faculty Council of the FMB. As examples of the action of the CONLIGAC, the following can be cited: organization of the calendar of scientific events, in such a way that no overlapping occurs; and the Congress of ALs of the FMB, which has been realized annually since 2006, with a central theme (e.g., urgencies and emergencies, infections, women's health) that is transversal and a unanimous choice.

The Leagues and Medical Formation: contributions and preoccupations

A study by Peres, Andrade and Garcia (2007), conducted with students of medicine using questionnaires, individual interviews and two focal groups, identified as principal motives for participating in extracurricular activities: "an attempt to fill the gaps in the curriculum, integrate with colleagues, supplement the course, achieve a sense of well-being and attend professional concerns" (Peres, Andrade & Garcia, 2007, p. 203).

The literature regarding the role of ALs and their impact on medical formation is scarce. However, some authors have analyzed the role of extracurricular activities and certain of their observations can be applied to ALs. Tavares et al. (2004) affirmed that these activities are extremely common and constitute "an important part of the training of the majority of Brazilian medical students, clearly serving as a complement to their training, which is know to be deficient in the majority of our schools" (Tavares et al., 2004, p 6).

Peres and Andrade (2005) realized an ample study regarding extracurricular activities, by means of an inquiry conducted with students of medicine, following by individual interviews and focal groups. The authors affirmed that despite an institutional culture that stimulated the formation of a "parallel" curriculum, little was known about the impact of these nonobligatory activities on psychosocial and cognitive development, academic efficiency and the adjustment of the student to the University. Such an "informal" or "occult" curriculum, that subverts the formal curricular structure, could be a development of expectations not contemplated by the instituted curriculum, contributing differentially to personal changes in the university in the five principal domains: academic knowledge and abilities, cognitive complexity, practical competence, interpersonal competence and humanitarianism. Based on the responses of 423 students of medicine to questionnaires, equivalent to a response rate of 70.3%, and other methodological strategies, the authors observed that students who participated in extracurricular activities developed several of them simultaneously, spending more than eight hours a week from the first to the forth year. Participation in an AL was the activity most frequently reported by students from the first to the third year, while "approaching medical practice" was the principal motive indicated by them. Other motives reported for participation in extracurricular activities were: compensate for frustrations in relation to the course and gaps in the curriculum, integrate with colleagues from different years and feel like a member of the institution, as well as attending future professional concerns. However, difficulties in administering the time, which has to be divided with academic obligations and leisure activities, were also indicated as sources of conflict (Peres & Andrade, 2005).

When evaluating extracurricular activities, Viera et al. (2004) administered a questionnaire for first to fourth year students of the medical course at the Ribeirão Preto Medical School (Faculdade de Medicina de Ribeirão Preto) of São Paulo University (USP). Of the total of 396 students matriculated in 2002, 362 were present on the occasion that the inquiry was conducted, with only two refusals. The authors observed that 92% of them were involved in some type of extracurricular activity. Among these, participation in an AL appeared in first place, with 73% of students stating they participated in them. Paradoxically, observation revealed a significant increase in the hours dedicated to such extracurricular activities in the final course years, compared to the first few, without the existence of greater time available in the curricular schedule. According to Peres, Andrade and Garcia (2007), in the final two years of the medicine course, the extracurricular activities most often developed are scientific initiation and monitoring, aimed at improving the curriculum vitae, rather than participation in ALs, more common in the first three years of the course (Peres, Andrade & Garcia, 2007, p. 207).

One possible contribution of ALs to professional formation is the inclusion of students belonging to different courses in the health area. Capovilla and Santos (2001) conducted a study with 87 odontology students from the fourth year day class at a private university. Based on the application of questionnaires using a five-point Likert scale, the authors observed that the impact of extracurricular activities on professional development was very positive. Indeed, the contributions probably extend beyond the area of health. Fior (2003) conducted a qualitative study with universities that had numerous courses in the areas of exact, human and biological sciences. The author sought "to investigate the optional activities realized by the graduate students, analyzing the relation established by the same between the participation in these activities and the personal changes perceived during graduation" (Fior, 2003, p 40). For this, the author interviewed 16 university students from a public university in the interior of the State of São Paulo, in the areas cited. Based on these interviews the author affirmed that:

‘the diversity of the activities developed by the students confirms that the educational process, under the responsibility of the institution, involves experiences that surpass the limits of the classroom and the demands of the obligatory curricular activities and that both, in interaction, contribute to significant changes in the learning and development of the students" (Fior, 2003, p.111).

With respect to the potentially positive aspects of the ALs, it is opportune to discuss distortions that can occur during the graduation course in relation to the creation and development of this type of extracurricular activity. Thus, it is fundamental that ALs do not deviate much from their primary function of university extension, diminishing or totaling ignoring activities of disease prevention and health promotion, for example, constituting solely scientific initiation or assistance activity. It would also not be desirable that they simply become extracurricular traineeships, with some classes, outpatient activities or nursing shifts in specific specializations. This would represent only additional work schedule, in the same form as routine academic activities, with passive, barely creative and minimally critical students. As Peres and Andrade (2005) highlighted, ALs can reproduce the same meritocratic logic and bureaucratized and hierarchical relations as the institution. It is known that the greater part of Brazilian medical schools are, unfortunately, characterized by a restriction of the object of practice (centered only on the biological individual), minimal insertion in adequate formation spaces (mostly focused on intramural spaces) and few opportunities for reflection and knowledge production, generating professionals who rarely question and who are inadequate for the health system and the job market (Azevedo & Dini, 2006).

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Another possible distortion is that participation in ALs only feeds a medical school environment already sufficiently competitive, such that actuation in these is only one more way to "fatten" the students' curriculum vitae with participation certificates or as a way of standing out before certain professors, while seeking future selection for residency programs. ALs should also not just play the role of merely anticipating curriculum content that will be offered later to the student, during the course.

The uncritical multiplication of ALs, without considering their academic and social relevance, the clarity and pedagogical coherence of their objectives, their model of management (sustainability, criteria for member entrance, interaction with other ALs) and their ideology (democratization, articulation with the Brazilian Public Health System (Sistema Único de Saúde - SUS), ample understanding of the processes of falling ill and respect for ethical and humanistic principals) is worrying.

According to Mafra (2006), the idea of ALs is being distorted and lead away from its true path, often understanding extension as assistentialism and not as an exchange of knowing between the community and the students inserted in this reality, seeking to resolve the difficulties encountered together.

From the point of view the participation of students in the directions of the institutions, it is fundamental that the ALs do not only fill the gaps in the curriculum, diminishing involvement and interest - of both the student body and professoriate - in discussions concerning necessary curriculum changes.

We run the risk that ALs become appendices of the curricular disciplines, a counterproductive mechanism of "pot hole-filling" (Mafra, 2006). They could end up functioning as "anesthetics" or "anxiolytics" to placate the anguish and demobilize the discussion and struggle for a curriculum that, in fact, prioritizes contents more relevant to the formation of the general physician.

It is important that ALs do not represent a precocious superspecialization, totally counter to the National Directives of Medical Teaching (Almeida, 2003) and the entire current discussion regarding the need for forming general physicians to act in the SUS, who have a wider vision of the health-disease process and always consider the patients in a non-compartmentalized way, a replete with signs, meanings, feelings, culture and knowing (Azevedo & Dini, 2006).

Finally, that the "good intentions" manifested by the organizers of the ALs and the orientation of the National Executive Board of the Students of Medicine (Direção Executiva Nacional dos Estudantes de Medicina, DENEM) carry weight, the ALs are spaces of power, subject to complex correlations of the forces existing in each institution and strongly influenced by the established ideology.

Finals considerations

The academic leagues can fulfill an interesting role in medical formation and they should remain cautious not to fall into the trap of being configured as mere reproductions of the existing distortions in medical formation, while in truth acting as a counterpoint to these problems. Ideally, within them, the students should have the opportunity to make choices actively and freely, show innovative initiative, exchange experiences and interact with colleagues interested in the same subjects and chosen by affinity.

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It is hoped that in this context, the students can acquire practical knowledge without pressure, with greater satisfaction and more significantly; develop intellectual, emotional and relationship potential, as well as critical and reflexive capacity; exercise creativity, spontaneity and leadership, more as actors and less as spectators of the teaching-learning process.

Thus, the ALs could definitively contribute to adequate formation of a humane and ethical, reflective and critical general physician, with a sense of social responsibility and commitment to citizenship; a professional capable of perceiving and listening to the patient in all their complex biopsychocultural integrality, capable of working, respectfully and constructively within a multidisciplinary team and disposed to actively and permanently seek knowledge. Finally, a professional that does not loose sight of the need to care for their own physical and mental health, in order to be a more efficient "carer" and satisfied with their professional role.

Faced with the lack of available literature regarding academic leagues and the magnitude of these within medical courses, empirical studies would be interesting, preferentially of a qualitative nature, to learn about the role of the phenomenon "academic league" in the formation of the students. We hope that the present article stimulates researchers in the area of medical teaching to develop research on this theme in our environment.

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The authors Albina Rodrigues Torres and Maria Cristina Pereira Lima participated equally in the elaboration of the article, the discussion, writing and in the revision of the text. Gabriel Martins de Oliveira and Fábio Massahito Yamamoto participated in the bibliographical review, discussions and in the writing of part of the manuscript.